Introduction and aims: There are significant gender differences in alcohol consumption throughout the world. Here we report the results of an alcohol consumption survey on the rural island of Savaii, in the Pacific nation of Samoa. Design and methods: Eleven villages were selected for sampling using a randomized stratified cluster sampling methodology. A total of 1049 inhabitants over the age of 40 years (485 males and 564 females) were surveyed about alcohol consumption over the past year, and a 72.2% participation rate was achieved. Results: A significant gender difference in alcohol consumption was found: 97.3% of women and 59.4% of men reported no alcohol consumption over the past year. This is one of the most significant gender differences in alcohol consumption in the world. No significant difference between genders was seen in those who consume only 1–5 alcoholic drinks per week (P = 0.8454). However, significantly more males than females consumed 6–25 drinks per week (P < 0.0001), 26–75 drinks per week (P < 0.0001), and 75+ drinks per week (P < 0.0001). Discussion and conclusion: This extreme gender difference in alcohol consumption is attributed to several factors, both general (alcoholic metabolism rates, risk-taking behaviors, general cultural taboos, etc) and specific to Samoa (church influence, financial disempowerment, and Samoan gender roles).